We remember the goal: making psychiatric care more available, accessible, and affordable while maintaining the highest standards. We remember the challenge: accomplishing this with limited resources. What we forget is the role played by our bad habits back then, our unverified claims of effective treatment, our poor record keeping and interminable therapies, and our readiness to opine about complex political matters as if we didn’t have a political agenda of our own, to name a few. Medical Handlers would be calling the game from here; they’d be the ones dealing the cards.
By the 1990s business and political leaders were on board and licensing authorities, agency administrators, state regulators, and health maintenance organizations in place, almost none medically trained, while a fiction of a timeless medical authority provided legal and reimbursement cover. Our role as psychopharmacologist-employee began expanding. Our other psychiatrist responsibilities began transferring to social workers, psychologists, and nurses who picked up that slack.
Adjusted schedules and adjusting relationships
More and more psychiatrist-therapists who formerly prescribed medications for symptom relief and optimal functioning were now salaried psychopharmacologist-employees seeing patients for 15 or 20 minutes and writing prescriptions lasting months to make time for increasing caseloads. Close monitoring for medication tolerance, effect, and adverse reactions was no longer feasible and a therapy relationship with patients impossible. The assigned therapist or counselor over whom the psychiatrist had no authority meanwhile was surreptitiously contributing to a stealthily dysfunctional silo-like alignment of the institution’s organizational tree that had the effect of souring intra-institutional collaboration.
Our new language of smoke and mirrors
We psychiatrists, for whom the clarity of words and their meaning traditionally held center stage, were now finding ourselves helpless to challenge an emerging vocabulary that peddled misinformation and bias and that compelled us to become unwitting carriers of misleading euphemisms and bogus concepts.
1) The patient as consumer. With medical practice now a business and with profit the dominant ethic, truth-in-advertising was monitored, and placebo fell out of use. Patients were now consumers, presumably to spare them the indignity of the label, patient, and doctors became service providers, to help dispel their elitist image. However, this new product labelling process had the unintended consequence of what was jokingly called the medicalization-of-life, where half the population would one day be in therapy with the other half. Activities, from art to exercise to assistance finding work to assistance in obtaining affordable housing, began appearing, not as part of a service plan but as part of a treatment plan, while teachers of language, art, and exercise were beginning to self-identify as language therapists, art therapists, and exercise therapists.
Behavioral health replaced mental health, signaling that it was how a person behaved—not how he or she thought or felt—that became the core issue requiring attention (see #4 Chemical restraint).
Dr Climo is the author of Psychiatrist on the Road: Encounters in Healing and Healthcare, an account of his Locum Tenens experience.
1. Rogers v Commissioner of Department of Mental Health. 390 Mass. 489; 1983.